Basic Information
| Provider Information | |||||||||
| NPI: | 1861726663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDONI | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARDONI | ||||||||
| OtherFirstName: | MEG | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5110 SOUTH YALE AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187797637 | ||||||||
| FaxNumber: | 9189386037 | ||||||||
| Practice Location | |||||||||
| Address1: | 5110 SOUTH YALE AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187797637 | ||||||||
| FaxNumber: | 9189386037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2009 | ||||||||
| LastUpdateDate: | 09/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC2200X | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.